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DIVISION OF WORKERS’ COMPENSATION
ELECTRONIC FUND TRANSFER ENROLLMENT FORM (For ACH only)
This form must be used by the Workers’ Compensation Insurance Carriers, the SelfInsured Employers and the SelfInsured
Groups or trusts who would like to make Second Injury Fund surcharge payments beginning in CY 2003 to the Missouri
Division of Workers’ Compensation (Division) through an Electronic Fund Transfer. Under the Missouri workers’
compensation law, Chapter 287 RSMo, the surcharge payments are deposited to the credit of the Second Injury Fund.
Recipients of this form should bring this information to the attention of their respective financial institution.
The funds transfer is governed by the Electronic Fund Transfer Act of 1978 (Title XX, Public Law 95630, 92 Stat. 3728, 15
U.S.C. Section 1693, et. seq.) as amended from time to time and Article 4A of the Uniform Commercial Code – Funds Transfer.
COMMERCIAL INSURANCE COMPANY INFORMATION
NAME
ADDRESS
NAIC NO. FEIN NO.
CONTACT PERSON NAME TITLE
EMAIL ADDRESS TELEPHONE NO.
EXEC. OFFICER PRINTED NAME TITLE
SIGNATURE DATE
SELF INSURED EMPLOYER/GROUP/TRUST INFORMATION
NAME
ADDRESS
NAIC NO. FEIN NO.
CONTACT PERSON NAME TITLE
EMAIL ADDRESS TELEPHONE NO.
EXEC. OFFICER PRINTED NAME TITLE
SIGNATURE DATE
DIVISION OF WORKERS’ COMPENSATION BANK INFORMATION
NAME ROUTING NUMBER ACCOUNT NUMBER
State of Missouri (Processing through Central Trust Bank) 086507174 6250081
This enrollment form may be amended only by submitting a new enrollment form reflecting the amendment to the Division, at
least thirty (30) days prior to the effective date of the amendment.
By signing this enrollment form, the executive officer of the Commercial Insurance Company, SelfInsured Employer or
Group/Trust warrants under penalty of perjury, that he/she has the necessary power and authority to complete this form and is
duly authorized to do so.
WC132 (0807) AI
If there has been a name or ownership change in the past 12 months, please indicate the previous name(s) or owner(s).
WC132 (0807) AI